Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
Do you screen for interstitial lung disease in patients with newly diagnosed polymyositis or dermatomyositis in the absence of respiratory symptoms?
I do screen all newly diagnosed IIM patients with PFTs and chest CT. This has a double purpose: establishing a baseline of lung function and, screening for lung cancer. While the patient might not have lung symptoms on presentation, respiratory involvement can manifest later on the course of the d...
What findings on routine monitoring PFTs prompt you to pursue HRCT in your patients with SARDs?
I don't think there is a way to set specific recommendations for this. Declines in physiology without other explanation, with or without symptoms, prompt me to get imaging. This is taking into consideration other things that affect the FVC and DLCO, but any significant decline (5% or greater?) would...
In patients with RA on methotrexate and a TNF inhibitor who develop PJP pneumonia, how long do you hold immunosuppression before restarting therapy?
I would typically hold immunosuppression until the patient has completed therapy unless they had significant respiratory failure, in which case I would await full recovery. The patient should be placed on appropriate PJP prophylaxis prior to resuming therapy.
How are you using liquid biopsy in the routine management of your patients with metastatic NSCLC?
The dramatic improvement in the prognosis of metastatic NSCLC patients harboring targetable oncogenic genetic alterations with highly effective therapy has underscored the need for tumor molecular profiling. There have been numerous studies in the past decade assessing the performance of ctDNA (here...
How do you counsel eligible patients on lung cancer screening who are hesitant because of the cancer risk from CT scans?
This is simple. The risk of lung cancer in patients who have smoked for >20 years is orders of magnitude higher than the theoretical risk of medical X-ray-induced cancers from low-dose CT (LDCT) screening. A typical LDCT scan exposes patients to approximately 1.5 mSv of radiation, equivalent to abou...
How do you manage a cytology-negative pleural effusion that develops after lung RT?
I think most times you can just watch them as long as they are stable and not symptomatic. I see them not infrequently after RT, especially lung SBRT, and find they often find a size they feel comfortable with and don't change much over time. I wonder about their physiology... my impression is there...
Do you recommend maintaining the same monitoring interval of PFTs every 3–6 months with HRCT as indicated for patients with anti-MDA5 dermatomyositis, or do you recommend closer surveillance in this group?
Closer surveillance may be needed at diagnosis of ILD in anti-MDA5 DM at every 3 months for 1st year. But typically, in my experience, patients' symptoms progress faster than every 3 months, so rapidly progressive ILD is diagnosed clinically.
What pharmacologic and non-pharmacologic strategies have you found helpful in managing brain fog following COVID-19 infection?
In general, a systematic approach should be taken to evaluate COVID-19-related brain fog, which can then guide treatment. Additionally, brain fog following COVID infection can often be multifactorial, and the treatment accordingly often needs to be multi-pronged and comprehensive. The recommendation...
When do you consider PET/CT to evaluate for an occult source of infection in patients with persistent bacteremia if TTE/TEE does not show evidence of endocarditis?
Great question. Generally, I consider PET/CT to evaluate for an occult source of infection in patients with persistent bacteremia if TTE/TEE does not show evidence of endocarditis, in the following scenarios: Persistent bacteremia ≥72 hours. TEE was negative or nondiagnostic. No source identified o...
Under what circumstances would you initiate antibiotics in adults hospitalized with RSV and a suspected bacterial co-infection?
Bacterial co-infection in patients hospitalized with RSV ranges between 8% and 29% (Karlsen et al., PMID 41488696). The American Thoracic Society 2025 guidelines recommend prescribing empiric antibiotics to all hospitalized patients with clinical and imaging evidence of community-acquired pneumonia ...